The Nutrition Debate #254: Saudi Approach to Diabetes

In this video interview with transcript from the recent European Association for the Study of Diabetes (EASD) meeting, Anne Peters, MD, at medscape.com, interviews Saudi MD and diabetologist Aus Alzaid. Dr. Peters asks, “…knowing the epidemic of diabetes that you are having in Saudi Arabia, can you tell us what diabetes care is like there?” Dr. Alzaid replies, citing International Diabetes Federation figures, that “Saudi Arabia has the highest rate of diabetes in the world after the small island nations in the Pacific.” Citing previous studies, he says, 1 in 4 people after the age of 30 has diabetes.”

But that it seems is part and parcel of the problem, Dr. Alzaid avers: “That part of the Middle East is steeped in history and tradition and culture, which means a lot to people. Then we have diabetes as a condition, which has to do with the person’s perception of the lifestyle modifications that must be made.” “I don’t know of any Saudi family that doesn’t have a member or two with diabetes,” he adds.

Dr. Peters replies by relating how she “work(s) with the Latino population in East Los Angeles where everybody just shrugs and says, ‘Everyone in my family has diabetes, so of course I have it too.’” In this respect I think the good doctors make a point. Resistance to change is strong, and fatalism commonly prevails. But would that be so if there was a “treatment” that worked? I read on in hope of enlightenment.

Dr. Peters: “Most healthy 30-year olds don’t go to the doctor. Are you making a push to convince young, healthy people to be checked earlier?”

Dr. Alzaid: “Absolutely, and there are messages going out about lifestyle modification. In our institution, we have Diabetes Awareness Day in November. [Whoopee!] It is still an overwhelming issue, and we are doing research to find out why we have such a high rate of diabetes.” [There’s money well spent…if it’s good research. Read on and you decide.]

Dr. Peters: “Have diet and rates of physical activity changed? What have you seen over the course of your career?”

Dr. Alzaid: “Decades ago, people were more mobile. Very little food was available in years gone by, but over recent decades, with the dividends of good fortune [oil revenue], there has been a ‘constant feast.’

Okay, the well-meaning Dr. Peters is turning the conversation to “diet and exercise,” the Western meme that we are eating too much and exercising too little. Well, at least the conversation is beginning to turn to diet. Let’s see where it goes.

Dr. Alzaid continues: “There are cultural things that we adhere to as part of our social etiquette. Food items such as rice and dates are very popular in our part of the world, and they are obviously very heavy in terms of calories. Fizzy drinks are commonly consumed.” That’s it, folks. That’s the good Saudi doctor’s understanding of nutrition, as captured in this Diabetes-in-Control piece. It’s all about calories-in/calories-out. True, there’s no mention of eating fat making you fat, or anything about dietary cholesterol. But neither is there so much as a word about carbohydrates (think ‘rice’ and ‘dates’).

Newsflash, Dr. Alzaid: Dates and rice and fizzy [sugary] drinks are all carbohydrates! Sugar and starch! 100 grams of pitted dates, about 4 Medjool dates, are 277 calories, of which 266 (96%) are sugar, 7 protein and 1 fat, plus a little indigestible fiber and ash. 100 grams of medium grain white rice, about 3.5 ounces, is 130 calories, of which 116 are carbohydrates, 10 protein and 2 fat. I don’t know what kind of “fizzy drinks” Saudis use to quaff their thirst, but I’ll assume (generously) it’s a Coca Cola. A 12 ounce (370g) cola is 152 calories, all sugar. That’s ten (10) teaspoons of sugar in one can of “fizzy drink.”

So, I think that Dr. Alzaid has identified the problem with the Saudi diet; he just hasn’t named it correctly. The “constant feast” he refers to is a carbohydrate feast, not a calorie feast. The fact that Dr. Alzaid describes “rice and dates” (part of the Saudi social etiquette) as “obviously very heavy in terms of calories” implies to me that it is his understanding that it is the calorie content of these foods, not the carbohydrate content, that is the cause of the Saudi diabetes epidemic. But what is there to do about it? It’s a cultural thing, and “that part of the Middle East is steeped in history and tradition and culture, which means a lot to people.” To which Dr. Peters replies, empathetically, ‘Everyone…has diabetes, so of course I have it too.’ Of course, it is a problem of education, which both doctors point out emphatically.

And the Saudi Ministry of Health has launched a public-awareness campaign “to tackle the problem with the right lifestyle.” The right lifestyle? Diet and exercise? Eat less (of the same carbohydrate-dominated diet) and move more? That is a lifestyle change that is guaranteed to fail. Diabetics are carbohydrate intolerant by definition. The best treatment for type 2 diabetes is a very low carbohydrate diet. The ‘right lifestyle’ to prevent type 2 diabetes is a reduced carbohydrate diet.